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The appearance of yet another rating scale for appear in different settings. Other symptoms are
measuring symptoms of mental disorder may seem difficult to define, except in terms of their settings,
unnecessary, since there are so many already in e.g., mild agitation and derealization. A more
existence and many of them have been extensively serious difficulty lies in the fallacy of naming. For
used. Unfortunately, it cannot be said that per- example, the term "delusions" covers schizophrenic,
fection has been achieved, and indeed, there is depressive, hypochrondriacal, and paranoid de-
considerable room for improvement. lusions. They are all quite different and should be
clearly distinguished. Another difficulty may be
Types of Rating Scale summarized by saying that the weights given to
The value of this one, and its limitations, can best symptoms should not be linear. Thus, in schizo-
be considered against its background, so it is useful phrenia, the amount of anxiety is of no importance,
to consider the limitations of the various rating whereas in anxiety states it is fundamental. Again,
scales extant. They can be classified into four a schizophrenic patient who has delusions is not
groups, the first of which has been devised for use necessarily worse than one who has not, but a
on normal subjects. Patients suffering from mental depressive patient who has, is much worse. Finally,
disorders score very highly on some of the variables although rating scales are not used for making a
and these high scores serve as a measure of their diagnosis, they should have some relation to it.
illness. Such scales can be very useful, but have Thus the schizophrenic patients should have a high
two defects: many symptoms are not found in score on schizophrenia and comparatively small
normal persons; and less obviously, but more scores on other syndromes. In practice, this does
important, there is a qualitative difference between not occur.
symptoms of mental illness and normal variations The present scale has been devised for use only on
of behaviour. The difference between the two is not patients already diagnosed as suffering from
a philosophical problem but a biological one. There affective disorder of depressive type. It is used for
is always a loss of function in illness, with impaired quantifying the results of an interview, and its value
efficiency. depends entirely on the skill of the interviewer in
Self-rating scales are popular because they are eliciting the necessary information. The interviewer
easy to administer. Aside from the notorious un- may, and should, use all information available to
reliability of self-assessment, such scales are of little help him with his interview and in making the final
use for semiliterate patients and are no use for assessment. The scale has undergone a number of
seriously ill patients who are unable to deal with changes since it was first tried out, and although
them. there is room for further improvement, it will be
Many rating scales for behaviour have been found efficient and simple in use. It has been found
devised for assessing the social adjustment of to be of great practical value in assessing results of
patients and their behaviour in the hospital ward. treatment.
They are very useful for their purpose but give little
or no information about symptoms. Description of the Rating Scale
Finally, a number of scales have been devised The scale contains 17 variables (see Appendix I).
specifically for rating symptoms of mental illness. Some are defined in terms of a series of categories
They cover the whole range of symptoms, but such of increasing intensity, while others are defined by a
all-inclusiveness has its disadvantages. In the first number of equal-valued terms (see Appendix II).
place, it is extremely difficult to differentiate some The form on which ratings are recorded also includes
symptoms, e.g., apathy, retardation, stupor. These four additional variables: Diurnal variation, de-
three look alike, but they are quite different and realization, paranoid symptoms, obsessional symp-
56
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58 MAX HAMILTON
TABLE I
CORRELATION MATRIX OF THE SCALE FOR DEPRESSION
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10 (11) (12 (13) (14 (15) (16) (07)
I Depressed mood 1-0 0-491 0-373 0-082 0-236 0-140 0-362 0 590 -0055 -0-198 -0-224 -0-032 0-014 -0-024 0-341 0-19
0 370
2 Guilt 1*0 0*522 -0-049 -0-048 0*121 0-358 0*370 0-027 -0*167 -0*151 0-071 -0003 0-426 0 113 0*419 0-22
3 Suicide 1.0 0 043 0-098 -0 073 0-016 0 335 -0-068 -0-216 -0-065 -0-087 -0-115 -0-042 0-201 0 13
0 304
4Insomnia, initial 1.0 0-199 0 309 0-130 -0-115 0-191 -0-001 -0-036 0-438 0-169 -0 044 0-152 0-179 0 U
5 ,, middle 1-0 0 054 0 035 0-200 0-126 0 003 0 095 0-308 0-278 0-111 0-067 0-146 0-rl
6 ,, delayed 1-0 0-17 0-126 0-022 -0-180 -0-162 0-376 -0-038 0-142 0 171 0-012 0-24
7Work and interests 1-0 0-230 0-183 0-017 -0-045 0-285 0-094 -0-058-0-020 0-313 0-17
8Retardation 1-0 -0 305 -0-365 -0-356 0-067 0-127 -0-208 0-232 0*04
0-269
9Agitation 1.0 0-274 0-329 0-199 -0 107 0-045 0 001 0-217 0-15
10Anxiety, psychic 1-0 0-3701-0-146 -0-058 -0-026 0043 -0-159 0Q24
11 ,, somatic 1 0 -0-082 0-060 -0014 -0-310 -_
0-033
12 Somatic, gastro-
intestinal 110 0-248 -0 115 0-135 0 074 0 3
13 Somatic general 10. 0-048 0-137 -0-024 -0 0
14 ,, genital 1-0 0-199 0-254 0-06
15 Hypochondriasis 1-0 0-275 0-23
16 Insight 10 0h4
17 Loss of weight 1.0
TABLE I I TABLE IV
FACTOR SATURATIONS AND LATENT ROOTS SATURATIONS OF ROTATED FACTORS
Condition Factor 1 Factor 2 Factor 3 Factor 4 Condition Factor I Factor 2 Factor 3 Factor 4
(1) Depressed mood 0 763 -0 172 0 103 0t151 (3) Suicide 0-674 -0009 -0-086 0O122
(2) Guilt 0-728 -0156 0-341 -0138 (14) Genital 0-618 0-113 0081 0 225
(3) Suicide 0-531 -0 311 0-283 0 122 -0-087 -0 138
(4) Insomnia, initial 0-207 0 614 -0-208 -0-025 (2) Guilt 0-783 0-224
(5)
(6)
,, middle
an delayed
0-284
0-338
0-363
0-371
-0-081
-0-304
0-639
-0-340
(8) Retardation 0-525 0-014
0-227
0-62a
-
-0309
0-224
0-151
(7) Work and interests 0-458 0-275 0-043 -0-134 (1) Depressed mood 0-690
(8) Retardation 0-683 -0-371 -0 253 0-224 (12) Somatic, gastro- 0-725 -0-288 -0 010
(9) Agitation -0 034 0 539 0 503 -0-032 intestinal -0-283
(10) Anxiety, psychic -0 373 0-326 0 557 0-072 (16) Loss of insight 0-508 0401 -0 ()'1'1 -0-173
(11) ,, somatic -0 403 0-250 0-480 0-421 (4) Insomnia, initial -0-214 0-637 -0-111 -0-025
(12) Somatic, gastro- (5) ,, middle 0-015 0456 -0105
intestinal 0-282 0-674 -0-395 -0-010 (7) Work and interests 0-245 0-466 -0102 -0-IJ4
(13) ,, general 0-087 0 245 -0-356 0-628 0-397 0123 1-0-144
(14) Genital 0-474 -0-139 0-397 0-225 (15) Hypochondriasis 0-024
(15) Hypochondriasis 0-157 0-367 0-117 -0-144 (17) Loss of weight 0-190 0 556 0-133 -0 192
(16) Insight 0-603 0-107 0-204 -0-173 (6) Insomnia, delayed -0-067 0490 -0-i -0 340)
(17) Loss of weight 0 353 0 439 0 214 -0 192 0.453 0-583 0-032
(9) Agitation 0-016
Latent root 3-4358 2-3439 1-7496 1-3658 (10) Anxiety, psychic -0-117 0-100 0 730 0-072
(11) ,I, somatic -0-148 -0-019 0-658 0421
(13) Somatic, general -0-227 0 256 -0-278 0-628
60 MAX HAMILTON
This patient had been off work for 11 years for "bad psychological stresses to account for the onset of
nerves" following an accident at work. He had many the present attack. In the first, the symptoms were
hypochondriacal complaints and had undergone many of the endogenous (retarded) type, and in the second
fruitless investigations. Four years ago, he was admitted of the reactive (agitated) type. Clinically, these
to hospital for severe depression with delusions and patients are very unlike, but the factor scores pick
hallucinations. This cleared after E.C.T. He was them out on account of their resemblance; what
readmitted a year ago, diagnosed as a case of reactive
depression, and improved slowly under general treat- this is, is not clear.
ment. He was discharged after three months. His Since the factors are derived from a limited
condition fluctuated and eventually he was readmitted, number of cases, the fourth factor is of very doubtful
given six courses of E.C.T. and showed marked im- stability. (The question of statistical significance
provement. He was discharged and remained well. is ignored for the moment.) Nevertheless, it is of
His symptoms were of moderate depression, without considerable interest. Both of the following patients
feelings of guilt or suicidal ideas. He had difficulty in showed depression with much anxiety, disturbance
falling asleep and awoke early. He showed moderate of sleep and many somatic symptoms, but it is the
loss of interest, anxiety, both psychic and somatic, and background to the illness that is noteworthy.
suffered from poor appetite and constipation. He was
diagnosed as a case of reactive depression, but the Factor 4.-A man aged 51 years (Case 62) had factor
relation of the illness to psychological precipitating scores of F1 39, F2 41, F3 56, and F4 71.
factors is not certain. This patient was a hard worker, but could not restrain
Case 17.-A man aged 72 years had factor scores of his heavy drinking and gambled heavily. These caused
F1 48, F2 65, F3 43, and F4 45. considerable marital discord. When temporarily out of
There was a long history of abdominal complaints, work after an accident, he stole money from his daughter
but investigations found nothing to account for them. to continue his "hobbies". He went off to London,
A year ago the patient became obviously depressed and stayed in a hotel and decamped without paying. When
was admitted to hospital. He showed moderate de- he eventually returned home, he heard that the theft had
pression, guilt, and some suicidal preoccupations. His been reported to the police. He became desperate, and
sleep was disturbed in all three phases. He showed loss after a few days attempted to gas himself and was
of interest, some agitation, severe hypochondriasis, and admitted to hospital. His condition cleared after E.C.T.
considerable anxiety. His appetite was poor, his bowels Case 7.-A man aged 44 years had factor scores of
were constipated, and he had lost weight. Because of F1 34, F2 44, F3 58, and F4 71.
the poor state of his heart, he was not given E.C.T. He This patient came from a disturbed parental home
improved slowly, finally discharging himself against where he had been rejected and deprived. He has
advice. Eventually he was admitted to a general hospital always been an odd personality with marked neurotic
and died from cancer of the lung. traits and paranoid attitudes. He served in the Royal
The clinical picture is that of reactive depression, but Air Force for nine years, during which he was repeatedly
the psychological precipitating factors are doubtful. delinquent and resistant to authority. Eventually he
Factor 3.-A man aged 61 years (Case 2) had factor was discharged for "psychoneurosis". His subsequent
scores of F1 41, F2 38, F3 63, and F4 44. occupational history is irregular, with frequent loss of
The patient had a history of several attacks of de- jobs because of quarrelling. He always feels that others
pression, the last one precipitated by the deaths of his are against him. He has not worked for years, has shown
ife and daughter. The course of the illness was much anxiety and in the last six months became depressed,
fluctuating, and the patient showed a poor response to being finally admitted to hospital. He improved a little
E.C.T. He showed marked depression, guilt, suicidal after E.C.T. but relapsed, subsequently recovering
thinking, retardation, loss of interest, and grossly spontaneously.
disturbed sleep. Eventually he recovered and has Both of these patients have obviously abnormal
remained well. personalities, although it would be an exaggeration
Case 45.-A man aged 53 years had factor scores of to describe them as psychopathic personalities. It
F1 60, F2 55, F3 78, and F4 52. has long been recognized that abnormal person-
The patient had had one previous attack of depression alities, particularly of the hysterical type, are liable
four years before. Two years ago, the patient again fell to attacks of depression, and it is of great interest
ill, and his symptoms have fluctuated considerably. In
hospital he showed much depression, guilt, and loss of that such patients should be picked out by reason
interest, much anxiety and agitation, loss of libido and of the pattern of symptoms of their depression.
loss of insight. He is a rather inadequate personality Nevertheless, the present findings should not be
and his present illness began when he was offered a post regarded as more than suggestive and worthy of
which involved greater responsibility. further investigation.
Both of these patients have had previous attacks Another way of tackling the relation between
of depression, characteristic of an endogenous type factors and clinical syndromes is to take groups of
of disorder, but in both cases, there were obvious clinically identified patients and compare their mean
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APPENDIX I
ASSESSMENT OF DEPRESSION
Item Score Symptom Score
No. Range
0-4 Depressed mood
0-4 Guilt
0-4 Suicide
0-2 Insomnia, initial
0-2 middle Grading
0-2 delayed
0-4 Work and interests 0 Absent
8 0-4 Retardation I Mild or trivial
9 0-2 Agitation 2
10
11
0-4
0-4
Anxiety, psychic
somatic
3j) Moderate
,, 4 Severe
12 0-2 Somatic symptoms, gastrointestinal
13 0-2 ,, general 0 Absent
14 0-2 Genital symptoms I Slight or doubtful
15 0-4 Hypochondriasis 2 Clearly present
16 0-2 Loss of insight
17 0-2 ,, _ weight
18 0-2 Diurnal variation {~ M
E
19 0-4 Depersonalization, etc.
20 0-4 Paranoid symptoms
21 0-2 Obsessional symptoms
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62 MAX HAMILTON
APPENDIX II
These include:
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Notes